In the payer and revenue cycle world, standardized vocabulary has been around for as long as most can remember, with ICD-9, CPT and the Healthcare Common Procedure Coding System (HCPCS). However, in the clinical world — for clinical documentation, orders and observations — there was no standard defined for common use across systems or between vendors.
As healthcare applications evolved, so did the need to express specific, granular and complex clinical information. Accompanying code sets emerged. Many, many code sets emerged, creating an alphabet soup of vocabularies: LOINC, SNOMED, MEDCIN, MESH, NDDF . . . and so on. And on. The Unified Medical Language System (UMLS) source list contains over 100 vocabulary sources.
Widespread use of standardized vocabularies will be essential for data sharing, care coordination, the ability to trend data and population management. The question is . . . which vocabulary? Many healthcare IT systems catalog very similar data under very diverse naming schemas, making the ability to receive and understand data across systems and care providers a huge challenge. One approach is to retrospectively map local names to standardized vocabularies. But when there are so many vocabularies – the process is costly and labor-intensive.
Why is this important? Change is happening rapidly, as ARRA mandates exchange of “semantically interoperable” information among care providers, and between care providers and patients. More than “view-only” data exchange, semantic interoperability means the information exchanged has the same meaning and attributes from the sending system to the receiving system. Widespread use of standardized vocabularies will be required. In the to-be-finalized requirements for “meaningful use,” standardized vocabularies for documentation, orders, results, units of measure, billing and coding will be defined. This will set up the need for every dictionary in an enterprise to be examined for compliance to the named standards.
Along with the changes coming in standardized clinical vocabularies, the U.S. is now mandated to move from ICD-9 to ICD-10 by October 1, 2013 and this will affect all components of the healthcare industry. This will enhance coding accuracy moving from the 12,000 codes in ICD-9 to the over 100,000 codes in ICD-10. Major changes in the code sets between ICD-9-CM and ICD-10 include not only a substantial increase in volume of codes, but changes in structure and detail – from a numeric, five-character size to an alphanumeric, seven-character size.
Then there’s another wrinkle – the language of these standardized vocabularies might not promote usability from a clinician’s viewpoint. So a key challenge coming up is to allow clinicians to capture problem lists and create orders in a language familiar to them while linking the problems at the back end to the standardized vocabulary.
How are you preparing for this journey to standardized clinical vocabularies?
